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Rapid Sequence Intubation

Intro to:. Rapid Sequence Intubation. Objectives. Define RSI Identify the Indicators for using RSI Identify the relative contraindications and disadvantages of RSI Discuss the different roles in the RSI process Review the crucial 7 P’s of RSI Review the medications used during RSI

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Rapid Sequence Intubation

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  1. Intro to: Rapid Sequence Intubation

  2. Objectives • Define RSI • Identify the Indicators for using RSI • Identify the relative contraindications and disadvantages of RSI • Discuss the different roles in the RSI process • Review the crucial 7 P’s of RSI • Review the medications used during RSI • Review a difficult airway and identify alternative tools and techniques

  3. What is RSI?

  4. Why RSI? • Respiratory failure • Inability to protect own airway • Impending or potential airway compromise • GCS less than 8 • Intractable seizures

  5. Relative contraindications to RSI • Airway obstruction • Distorted anatomy • Major facial or laryngeal trauma • Angioedema

  6. Disadvantages of RSI • Hypoxia if unable to complete intubation • RSI blocks the patient’s involuntary reflexes and muscle tone in the oropharynx and larynx • Adverse medication reactions • Masks underlying symptoms • Requires considerable amount of training and recurrent training

  7. The benefit of obtaining airway control must always be weighed against the risk of complications in these patients. • You are taking a breathing patient and making them APNEIC

  8. RSI Equipment • Airway equipment (ET, syringe, stylette, etc) • Oxygen • Suction equipment • Ecg monitor • IV equipment • SaO2 monitor • Capnography • RSI meds

  9. It’s a team effort! • Skilled intubator • Timekeeper/scribe • Vital sign monitor • Medication administrator • Assistant

  10. Before you get started…. In the ideal world • Get medical history • Obtain baseline neuro exam • Check all your equipment • Confirm pt. weight

  11. 7 Essential P’s of RSI • Preparation • Pre-oxygenate • Pre-medicate • Paralysis and Induction • Protection • Placement of the tube • Post Intubation management

  12. Preparation • Prepare all equipment including ETT, suction, pulse oximeter, IV and monitor • Position patient in sniff position if C-spine immobilization is not indicated.

  13. Pre-Oxygenate • Pre-oxygenate with 100% oxygen via NRB for at least 3 min. or 8 vital capacity breaths with 100% oxygen. • If ventilatory assistance is necessary with BVM, be gentle and apply cricoid pressure.

  14. Do you predict a difficult airway? • Short neck or no neck • Small mandible • Obesity • Facial/maxillary trauma • Edema or infection • Degenerative spinal disease

  15. What does a difficult airway mean to you? • Be prepared! • Have plan B, C, and D if intubation fails.

  16. Tools for a difficult airway • Have one ETT tube size smaller & bigger available • ETTI (Bougie, Eshman, etc) • Back up devices (Combitube, King airway) • Surgical airway kit

  17. Are you ready?

  18. What drugs do we use? • Oxygen • Ventilate while preparing for RSI • Lidocaine? • Atropine? • Versed • Etomidate • Succinylcholine • Vecuronium

  19. Procedure • Pre-oxygenate – (NOT hyperventilate) for 2 – 3 min. • Assemble equipment • Proximal IV preferred • Connect pt. To monitor • Lidocaine (TBI) • Atropine (children < 10) • Versed • Etomidate • Succinylcholine • Sellick maneuver

  20. Procedure, cont. • Stop ventilations • Observe for fasiculations • Intubate • If unable to ventilate in 20 sec. , stop and ventilate for 30 – 60 sec. • May give second dose of Sux (1 – 1.5 time initial dose • If bradycardia occurs, give Atropine and hyperventilate • Confirm intubation • Attach Easy Cap or capnography device • Administer Vecuronium • MONITOR PATIENT

  21. Protect the Patient • Maintain cervical stabilization prn • Maintain cricoid pressure until tube placement is confirmed and secured. • Constant vigilance of monitoring oxygenation

  22. Whose tube is it? • The most experienced medic! • If unable to intubate within 20 seconds or SaO2 drops below 92%, STOP and ventilate with BVM • Confirm placement • Release cricoid pressure

  23. How did you confirm the tube? • Gold standard (visualized tube passing through the cords • Capnography • Mist in the tube • Bilateral breath sounds Recheck tube placement after every patient move, if airway resistance occurs or increases, hear rate decreases, or O2 desaturation occurs

  24. Post medication • Continue paralysis with Vecuronium • Continue sedation with Versed • Consider pain control

  25. What if you can’t get the tube in?? • Provide 100% oxygen with BVM • Consider back up device • Consider surgical airway

  26. All neuromuscular Blocking Agents: • Work by blocking the natural transmission of nerve impulses to skeletal muscles. • No direct effect on Heart, Digestive system, Brain, Pupillary response, Smooth Muscle or other organ systems • No effect on mentation or pain perception! • No direct effect on seizure activity.

  27. Remember…. • If performed correctly, RSI will take between 7 – 10 minutes. • You are taking a breathing patient and making them apneic. • Always be prepared and know your RSI protocol.

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